At Home Personal Care Services
(703) 330-2323
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Employment Application Form
Step
1
of
4
- Personal Information
25%
Step-1 Personal Information
First Name
*
Last Name
*
Date of Birth
MM slash DD slash YYYY
Other Name (If Applicable)
Social Security Number
CURRENT ADDRESS
Street
*
Apart Number
City
*
State
*
Zip
*
Time Spent at This Address
*
PREVIOUS ADDRESS
Street
Apart Number
City
State
Zip
Time Spent at This Address
Home Phone
*
Cell Phone
Other Phone
Email
*
If hired, can you provide proof of legal right to work in the US?
*
Yes
No
Position Applying for
Administrative
RN
Regional DON
LPN
HHA
PCA
Homemaker
PT/OT/RT
MSW
Clerical
Other
Referral Source
Walk-In
Government Employment Agency
Employee
Relative
School
Person
Other
Step-2 Education History
High School Name and Address
Did You Graduate?
Yes
No
Course of Major
Diploma or Degree
Year Completed
College Name and Address
Did You Graduate?
Yes
No
Course of Major
Diploma or Degree
Year Completed
Graduate School Name and Address
Did You Graduate?
Yes
No
Course of Major
Diploma or Degree
Year Completed
Business School Name and Address
Did You Graduate
Yes
No
Course Major
Diploma or Degree
Year Completed
Training Program Name and Address
Did You Graduate?
Yes
No
Course Major
Diploma or Degree
Year Completed
Step-3 Previous Work History
Previous Employer Name
Address
Phone
Start Date
End Date
Job Title
Supervisor's Name
Salary
Reason for Leaving
Previous Employer Name
Address
Phone
Start Date
End Date
Job Title
Supervisor's Name
Salary
Reason for Leaving
Previous Employer Name
Address
Phone
Start Date
End Date
Job Title
Supervisor's Name
Salary
Reason for Leaving
Additional References
Name
Address / Phone Number
Relationship
Name
Address / Phone Number
Relationship
Name
Address / Phone Number
Relationship
Step-4 Availability
HHA Hours Available (Check all that apply)
4 Hours (AM)
4 Hours (PM)
8 Hours
12 Hours (AM)
12 Hours (PM)
Live-in
Applying For :
Full Time
Part Time
I Prefer ;
Days
Evenings
I am flexible
Enter Your Available Hours Below
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Will you work overtime (if required)
Yes
No
If no, please explain
Position Desired
Salary Desired
Date you can start
MM slash DD slash YYYY
Have you ever been bonded?
Yes
No
If yes, by whom?
Have you ever been convicted of a crime?
Yes
No
If yes, please explain
Professional Licences
Profession
License No:
Exp. Date:
Verification Date / Person
Have you ever been sanctioned by Medicare / Medicaid?
Yes
No
School / Training Program:
Para-Professional Education:
HHA
PCA
Verification Date / Person
List any foreign language(s) other than English and your skill level.
List any additional information you would like us to consider.
I certify that the information given by me is true and correct and without any omission. I understand and agree that any false statement or intentional omission on this application or any subsequently furnished from constitutes cause for discharge at any time during my employment by At Home Personal Care Services, LLC. (AHPCS)
I authorize AHPCS investigate all statements made in this application. I further authorize AHPCS to make any investigation of my credit, criminal and driving records in connection with this application and anytime thereafter in connection with my employment.
I authorize the references listed in this application, to provide AHPCS will all information concerning my previous employment and any other pertinent information about me that they may have.
I understand that all information obtained during pre-employment screening is held by AHPCS in confidence and will not be released to a third party unless AHPCS is required by law or is specifically authorized to do so by me.
I further understand that if I am hired, I will not have an employment contract and that my employment and compensation can be changed or terminated with or without notice or cause at any time by AHPCS.
AHPCS is an equal opportunity employer. We do not discriminate because of age, race, creed, color, sexual orientation, disability, citizenship status, national origin, marital status, veterans status or the presence of a non-job related medical condition or handicap or any other legally protected status.
Phone
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